88-2027 - Laserfiche WebLink

Home Browse Search

I 1 t APPLICATION FOR PERMIT + SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone {209)466-6781' PERMIT EXPIRES 'I YEAR'FROM DATE 19SUED >' t. F AUG 3 1988 (Complete in;Triplicaie1' ENVIRONMENT Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein dei1 H � H made in compliance with San Joaquin County Ordinance No 549 for sewage or No. 1862 for well/pump and the Rules and Regulations off �uin N'Locai Health District. �a,� ,:. r �« L : n .y. � � ,r Job Address _l— .lt�i' tl c `t. #k y City L'ot Size 3 PM Owner's Name - Address / � c.) ti� Phone Contractor - _ Address -� License No.�Phone2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a FOUNDATION AGRICULTURE WELL ! ; OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open Bottom ❑ Manteca Dia:,of Well Excavation Dia. of Well Casing i%Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑Public ❑ Other +: ❑ Delta De th of Grout Se ' R ; aJ" Type of Grout `L ' ❑ Irrigation Approx. Dep ❑ Eastern Surface Seal installed by T Repair Work Dane J. Type of Pump:} M.P. f � �1 " -- i Sate Work Done � . Well Destruction ❑ Well Diameter 3 Sealing Materia! ft.-p"501 r Depth Filler Material 1B'elow,50') Q ' TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION 11 ;DESTRUCT ION © {No septic system permitted if public sewer is s available within 200 feet.) 1. Installation will serve: Residence_ Commercial— Other Number of living units: Number7af bedrooms Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity `' No. Compartments S 1 PKG. TREATMENT PLT. ❑ ___._Methodof.Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines g Total length/size - � FILTER BED ❑ Distance to nearest: We11Foundation ' 't Property Line SEEPAGE PITS ❑• Depth -Size 'e Number � SUMPS �_O__ L1 Well to nearest: Well Foundation—�-- _-.— Property Line- 6- ISPOSAL PONDS ❑ I €'.yQ hereby certify that I have prepared this application and that the work will be done iii accordance with San Joaquin county ordinances, state laws, and 3 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "i certify that in the'performance of the work for which this permit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 1. The applicant must ail f I required inspections. Complete drawing on r rsa side. Signed 9J� f Title: Date: 1 O DEP TMENT USE ONLY ' Application Accepted-by Area � Pit or Grout Inspection by Date Final Inspection by z7fzw Date+'' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 l ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY, _ DATE PERMIT'NO. INFO H 11 {�� CASH + EH 13-241REV.1/85) ld 2�- � �.7.1 3S .OD )„[}fl� F y� �• G �f U Q '�/� �f EH 14-26 �F•f J W Wq o` l 1 l